NURSING CARE PLAN

ASSESSMENT/ NURSING BACKGROUND GOAL & NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS
Subjective: Risk for Fluid Susceptible to NOC: Fluid Balance NIC: Fluid monitor Goal Partially Met:
N/A Volume experiencing,
Deficit decreased NOC: Fluid balance
related to intravascular,
increased interstitial, and/or
Objective: body Intracellular fluid GOAL: After 1 hour GOAL:
temperature volumes, which of nursing intervention, After 1 hour of nursing
VITAL SIGNS: may compromise the patient will Administer antipyretic intervention, the patient
RR: 32 health maintain a normal body medication as ordered was able to maintain a
PR: 177 temperature (< 37.5°C) by the physician to normal body temperature
for 24 hours without
O2: 95 help reduce the child's (< 37.5°C) for 24 hours
antipyretic medication.
TEMPERATURE: fever and discomfort. without antipyretic
medication.
39.5

Apply Cooling
OBJECTIVE: After 30
Measures, Use sponge
mins of nursing
baths or cool intervention the patient
OBJECTIVE: After
compresses on the was able to:
30 mins of nursing
intervention the child's forehead, neck,
patient will be able to: and armpits to help
lower body
temperature and
1. decreased body provide relief from 1. decreased body
temperature by fever-related temperature by at
at least 1°C discomfort. least 0.5°C
compared to compared to
Encourage Fluid
 baseline. Intake, Offer the child baseline.
small sips of clear
2. consume at fluids, such as water or 2. consume at least
least 500 ml of oral rehydration 500 ml of fluid
fluid orally. solutions, at frequent orally.
intervals to prevent
3. show dehydration and 3. show
understanding promote comfort. understanding of
of the the importance of
importance of Educate So about fever drinking fluids
drinking fluids management strategies, during fever
during fever including fluid intake episodes through
episodes encouragement, and simple verbal cues
through simple when to seek medical or gestures.
verbal cues or attention if fever
gestures. persists or worsens. 4. temperature trend
Proper hydration will show a
helps regulate body decrease in fever
temperature and spikes or a
prevents dehydration. sustained decrease
in temperature
over time, as
observed through
Regularly assess the axillary
4. temperature child's temperature, temperature
trend will show heart rate, respiratory measurements.
a sustained rate, and oxygen
decrease in saturation to monitor
temperature the effectiveness of
over time, as fever management
observed
through axillary interventions and
temperature detect any signs of
measurements. deterioration.

Monitor Urine Output,

Keep track of the
child's urine output by
counting wet diapers
to ensure adequate
hydration and early
detection of
dehydration.
Monitor for Signs of
Complications: Watch
for signs of
dehydration, such as
dry lips, sunken eyes,
or decreased urine
output, and report any
concerning symptoms
to the healthcare
provider promptly for
further evaluation and
management.